Jan 2017

UNIVERSITY OF CALIFORNIA, LOS ANGELES

Investigators’ Statements of Financial Interests Under UCLA Policy 925, the Principal Investigator and all other UCLA Investigators who share responsibility for the design conduct, or reporting of certain sponsored projects must report their personal financial interests in any organization(s) that, to the best of the Investigator’s knowledge, may have a significant impact on the conduct of this research or might benefit from the anticipated results of the proposed project.

Sponsor: (please check one box below)

Federal Agency (specify) __________________________ UC Special Research Programs Subaward from Federal Agency (specify) __________________ CIRM Other ___________________________

Reason for Disclosure: New Proposal Additional Support New Investigator New Interest(s) Obtained

IRB Request Voluntary Disclosure Other _______________________________

Title of Proposal: ____________________________________________________________________________________

_________________________________________________________________________________________________

IRB/ARC No(s) (if applicable): ________________________________________________________________________

Disclosure and Certification

The Principal Investigator's signature certifies that all individuals required to make disclosures of Significant Financial Interests have been listed on this form, or that no other individuals working on the research are required to make such disclosures:

Are there other Investigators who share responsibility for the design, conduct, or reporting of the research? No Yes

If YES, those Investigators must sign and complete the section below.

All Investigators named below acknowledge their responsibility to disclose any new Significant Financial Interests acquired during the term of the award.

Do you, your spouse or registered domestic partner, or dependent children have a Significant Financial Interest related to the work to be conducted under the proposed project? (See reverse for definitions of Significant Financial Interests)

1. ________________________________________________ NO YES, Form 740 Supplement attached Signature (Principal Investigator) Date

______________________________________________Print or Type Name of Principal Investigator

2. ________________________________________________ NO YES, Form 740 Supplement attached Signature Date

________________________________________________Print or Type Name of Other Investigator

3. ________________________________________________ NO YES, Form 740 Supplement attached Signature Date

________________________________________________Print or Type Name of Other Investigator

4. ________________________________________________ NO YES, Form 740 Supplement attached Signature Date

________________________________________________Print or Type Name of Other Investigator

Form 740

Significant Financial Interest(s): Significant Financial Interests include but are not limited to:

Income including salary or other payment for services including consulting fees, honoraria, reimbursement of expenses(including travel), royalty payments, dividends, loans from an entity, or any other payments or consideration with value,including payments made to a health sciences compensation plan, during the prior twelve months or anticipated in thenext twelve months, of $10,000 or more;

Equity in the form of stock, stock options, warrants, real estate, loans to or from an entity, or any other investment orownership interest exceeding either $10,000 (current market value if publicly traded; otherwise, amount of investment) ora 5% ownership interest, for any one enterprise;

A management position, whether paid or unpaid, such as board member, director, officer, partner, or trustee;

All intellectual property interests such as patents, patent applications, trademarks and copyrightable software (but notscholarly publications or other published works) that you own or is controlled by an individual or party other than TheRegents, irrespective of whether such intellectual property has resulted in any income.

Reporting is for the individual, his/her spouse or registered domestic partner, and dependent children. Specifically excluded from the definition of Significant Financial Interests are intellectual property owned by The Regents and payments made by The Regents for remuneration from the University including salary, stipends, honoraria, reimbursement of expenses and royalty payments.

Under the California Public Records Act, this information may be made available to the public upon request.

New Proposal: OffAdditional Support: OffNew Investigator: OffNew Interests Obtained: OffIRB Request: OffNo Cost Time Extension: OffOther: OffAre there other Investigators who share responsibility for the design conduct or reporting of the research: OffYES Form 740 Supplement attached_4: OffPrint or Type Name of Other Investigator: Print or Type Name of Principal Investigator: Print or Type Name of Other Investigator 3: Print or Type Name of Other Investigator 4: Date 1: Date 2: Date 3: Date 4: IRBARC Nos if applicable: Other 2: Title of Proposal 2: Title of Proposal: CIRM: OffUC Special Research Programs: OffFederal Agency Specify: Federal Agency: OffSubaward Specify: Other Specify: Subaward: OffOther (check): OffYES Form 740 Supplement attached: OffNO 1: OffYES Form 740 Supplement attached_2: OffNO 2: OffNO 3: OffYES Form 740 Supplement attached_3: OffNO 4: OffPRINT FORM: CLEAR: